CNS Functioning
Preliminary Assessment

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* - indicates required information
First Name
Last Name *
Date of Birth (dd/mm/yy)
Return E-Mail Address*
Work Phone
Non-work Phone

Are you able to drive a motor vehicle? Yes Partially No
Are you able to work or study? Yes Partially No
Are you able to sustain a close relationship with someone? Yes Partially No

Please pick a number from 0-to-10 to indicate how frequently do you have problems in the areas listed below. "0" means Not at all, and "10" means "All the time".

If one or more of your parents had this, or a similar problem, check the column headed by "Parents?"

If the problem came on suddenly, Check the column head by "Suddenly?"

Sensory Frequency Parents? Suddenly?
Light, in general, or lights, bother you
Problems with the sense of smell
Problems with vision
Problems with hearing
Problems with the sense of touch

Emotions Frequency Parents? Suddenly?
Problems of sudden, unexplained changes in mood
Problems of sudden, unexplained fearfulness
Problems of unexplained spells of depression
Problems of unexplained spells of elation
Problems with explosiveness
Problems with irritability
Problems with suicidal thoughts or actions

Clarity Frequency Parents? Suddenly?
Feel "foggy" and have problems with clarity
Problems following conversations
(with good hearing)
Problems with confusion
Problems following what you are reading
Realize you have no idea what you have been reading
Problems with concentration
Problems with attention
Problems with sequencing
Problems with prioritizing
Problems not finishing what you start
Problems organizing your room,
office, paperwork
Problems with getting lost in daydreaming
You cover up that you don't know what
was said or asked of you

Energy Frequency Parents? Suddenly?
Problems with stamina
Fatigue during the day
Trouble sleeping at night
Problems awakening at night
Problems falling asleep again

Memory Frequency Parents? Suddenly?
Forget what you have just heard
Forget what you are doing, what you need to do
Problems with procrastination and lack of initiative
Problems not learning from experience

Movement Frequency Parents? Suddenly?
Problems with paralysis of one or more limbs
Problems focusing or converging the eyes

Pain Frequency Parents? Suddenly?
Head pain that is steady
Head pain that is throbbing
Shoulder and neck pain
Wrist pain
Knee pain
All-over pain
Joint pain
Other pain:

Other Problems Frequency Parents? Suddenly?
Problems with nausea
Skin problems
Problems with speech or articulation
Noise in ears (Tinnitus)